Iris Elaine Fordham · Prevention of Future Deaths report

On 2nd January 2023 this Court commenced an investigation into the death of Iris Elaine Fordham aged 95 years. The investigation concluded at the end of the inquest on 5th October 2023. The court returned a narrative conclusion;

Iris Elaine Fordham died in a step-down care centre on 1st January 2023, she was recovering from a surgical repair of injuries sustained in a fall. Her death was caused by worsening symptoms of Alzheimer's disease.

Mrs Fordham's medical cause of death was determined as;

1.a. Alzheimer's disease
2. COVID-19, fractured neck of femur, suspected colorectal cancer

Iris Fordham was admitted to hospital on 22nd November 2022 having sustained an unwitnessed fall in the community, her admission was not to treat any traumatic injury, but rather that concerns existed about her ability to ensure her own safety due to Alzheimer's disease.

Mrs Fordham was placed on 1:1 nursing care in order to, amongst other things, mitigate the risk of further falls.

Those caring for Mrs Fordham failed to conduct a falls risk assessment, introduce a falls care plan, or conduct an enhanced care assessment when indicated. The successive failings resulted in removal of 1:1 care and then an unwitnessed fall on 25th November 2022. Mrs Fordham sustained a broken neck of femur and underwent a surgical repair. Post surgically, she was transferred to a step-down care centre where she died on 1st January 2023.

1. The poor quality of recording clinical records impeded the Trust's governance processes, in that the author of a serious incident investigation was unable to rely on clear evidence to understand why essential actions were not carried out in Ms Fordham's care.

2. The Trust failed to complete a falls risk assessment of Ms Fordham.

3. The consequence of (2) was that no falls care plan was completed.

4. The fact that the failures at (2) & (3) were not detected and remediated by successive clinical staff members suggests that they did not read essential parts of the clinical record when providing care. The cumulative failings, on the part of multiple healthcare professionals suggests a culture of indifference inimical to the provision of safe and effective practice.

5. The Trust has not considered any step to resolve individual failings in care through disciplinary or regulatory channels.